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Some internationally trained doctors are being allowed to practise during COVID-19, but what happens after?

Canada’s health-care workforce has been hit hard by the COVID-19 pandemic, with over 3,600 health-care workers testing positive for the virus so far. Early on, the pressure that COVID-19 was expected to put on the health-care system forced policymakers to consider new measures to increase their supply of doctors. One of those measures was the introduction of a certificate that would allow internationally trained doctors without Canadian medical licenses to practise in Ontario temporarily under certain strict conditions.

The new temporary licensing policy, called the Supervised Short-Duration Certificate, dips into Ontario’s supply of international medical graduates (IMGs), many of whom are currently unable to work in their fields. (IMGs also include Canadian citizens who studied medicine abroad.) A similar measure in British Columbia also allows internationally trained doctors to practise during the pandemic.

But these new measures highlight the long-standing difficulties internationally trained doctors face when trying to gain their full medical license in Canada. In Ontario alone, there are 13,000 internationally trained doctors who are not currently working in their field according to statistics from HealthForceOntario. The new measures seek to use the untapped potential of these IMGs, but they also raise the question: Why wasn’t Canada employing this skilled workforce already?

For an IMG to become a fully licensed doctor in Ontario, they need to have graduated with a medical degree from a university recognized in the World Directory of Medical Schools, pass a series of written and practical exams, and complete a residency program. While Canadian-trained graduates have a similar licensing process, IMGs sometimes encounter more barriers along the way.

One of the main obstacles IMGs face is at the residency stage. Provinces set aside a limited number of residency spaces for IMGs — far fewer than the number who apply — creating a bottleneck of qualified applicants and making it difficult for graduates to proceed to the next step in their medical licensing qualifications.

I think at some point we need to ask the question: Shouldn’t residency seats go to the individual who is going to make the greatest contribution— Deidre Lake

“I understand that, as a medical system, we invest in our Canadian medical graduates,” says Deidre Lake, executive director of the Alberta International Medical Graduates Association (AIMGA). “But we also have IMGs coming with training and experience that we haven’t paid for, and that has been really, in some sense, a cost savings, and yet we’re only letting them apply for a limited number of seats.”

“I think at some point we need to ask the question: Shouldn’t residency seats go to the individual who is going to make the greatest contribution and shouldn’t IMGs have a fair chance applying for residency seats alongside Canadian medical graduates?” she says.

Even after the COVID-19 pandemic, Canada could help address its low number of doctors by tapping into this reserve of international medical graduates waiting to practise. Canada currently ranks twenty-fifth among Organisation for Economic Co-operation and Development (OECD) countries when it comes to the ratio of doctors to population, with 2.8 doctors per 1,000 inhabitants. Austria, first on the list, has nearly double that figure, with 5.2 doctors per 1,000 inhabitants.

Canada also has comparatively long wait times for specialist appointments and emergency room care compared to other industrialized countries, as well as a lack of family physicians in some provinces — which could be linked to the country’s shortage of doctors, according to a 2018 report from the Fraser Institute.

Current trends suggest we will see only “a small increase in the physician-to-population ratio” between now and 2030. And, if we factor in the current rate at which IMGs are entering health care, “the ratio will only improve from 2.74 physicians per thousand population in 2015 to 2.97 in 2030” without considerable increases, the report states.

In addition to policy issues, potential bias toward immigrant IMGs could also pose a barrier to those trying to practise in Canada. One study published in the medical journal Canadian Family Physician found that, though immigrant IMGs tended to have more years of training and clinical experience, “a relatively greater proportion of Canadian IMGs” were successful in obtaining residency positions.

Not only that, the limited number of immigrant IMGs who are eventually accepted into residency programs are more likely than their Canadian counterparts to experience discrimination on the basis of their background. A 2011 study of discriminatory behaviour experienced by family medicine residents in Alberta found that “a significantly greater proportion of [immigrant] IMGs perceived ethnicity, culture, or language” to be the basis of the discrimination they experienced, mostly in the form of “inappropriate verbal comments.”

Despite the issues IMGs face because of the country they come from or where they have studied, having a diversity of experience in health care can have many positive effects — and some IMGs have been able to put their cross-cultural and multilingual skills to use during the COVID-19 pandemic, including those who haven’t gained short-term certification. AIMGA has put together videos, written material, and digital information sessions about COVID-19 in several languages, translated by its diverse group of over 1,000 members from more than eighty countries.

AIMGA also assisted Alberta Health Services by calling 500 workers in the midst of a COVID-19 outbreak at a meatpacking plant in order to give them more information about the virus. Sixty percent of the calls were to Filipino workers, conducted with the help of four Filipino AIMGA members who were able to communicate with them in their native language about the risks and symptoms associated with COVID-19.

We have members who are working as Uber drivers, who are working as health-care aides, or at a warehouse, or in a security position, and that's certainly not what they had in mind when they chose to immigrate to Canada— Deidre Lake

The volunteers engaged in this work do so, says Deidre Lake, because being a physician is their calling, and the urge to help others — especially during a medical crisis — is hard to ignore. “It really is detrimental to the individual, to the community, and to society when you have a highly educated, highly skilled individual who is unable to utilize their skills and knowledge,” she says.

But is asking IMGs to put themselves in harm’s way during a pandemic without also allowing for more long-term licensing options fair? Seventy-six physicians in Ontario are known to have contracted COVID-19 so far, and as the health-care system continues to be affected by hundreds of new cases in Ontario each day, the strain on the province’s physicians will likely continue to grow.

Meanwhile, a significant supply of IMGs — some of whom specialize or have experience in fields relevant to COVID-19, like ventilation and infectious diseases — languish in a state of unemployment or underemployment.

“We have members who are working as Uber drivers, who are working as health-care aides, or at a warehouse, or in a security position, and that’s certainly not what they had in mind when they chose to immigrate to Canada,” says Lake. “It’s heartbreaking, really, when we as a country can’t utilize the skills and knowledge that they’re coming with.”